title: Population-based estimates of survival benefit associated with combined modality therapy in elderly patients with locally advanced non-small cell lung cancer.
abstract: OBJECTIVE
  Combined modality therapy (CMT; radiation and chemotherapy) is indicated for fit, elderly patients with inoperable, locally advanced non-small cell lung cancer. We used population level data to examine effects of CMT on survival.
  
  
  METHODS
  Medicare patients who are 66 years or older with locally advanced non-small cell lung cancer (stages IIIA and IIIB without pleural effusion) from 1997 to 2002 were identified in Surveillance Epidemiology and End Results-Medicare. Detailed insurance claims were used to characterize treatment modality (none, chemotherapy only, radiotherapy only [XRT-ONLY], or CMT). CMT was further categorized as sequential (CMT-SEQ), or concurrent chemoradiation alone (CMT-ONLY), with induction (CMT-IND), or with consolidation chemotherapy (CMT-CON). Nonparametric models estimated survival effects of treatment regimens, controlling for patient characteristics, including claims-based indicators of performance status. Propensity score analysis adjusted for treatment selection.
  
  
  RESULTS
  Of the 6325 patients, 66% received therapy, with 41% (N = 1745) receiving XRT-ONLY and 45% (N = 1909) receiving CMT (12.5% CMT-SEQ, 35.3% CMT-ONLY, 11.3% CMT-IND, and 20.3% with CMT-CON). CMT had a survival benefit relative to XRT-ONLY (hazard ratio: 0.782, 95% confidence interval: 0.750-0.816; additional 4.4 months median survival; adjusted 10.7% increase in 1-year survival). Relative to CMT-SEQ, concurrent CMT-ONLY was associated with an increased mortality risk, whereas CMT-IND regimens provided a survival benefit (hazard ratio: 0.731, 95% confidence interval: 0.600-0.891; additional 3.8 months; and adjusted 14.4% increase in 1-year survival).
  
  
  CONCLUSIONS
  Survival benefits associated with CMT in clinical trials can extend to the elderly in routine care settings. CMT-ONLY is associated with the greatest mortality risk, suggesting that more gradual strategies (CMT-IND) may be more appropriate for the elderly population.
authors.affiliation: University of Maryland Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland 21201, USA. adavidof@rx.umaryland.edu
authors.forename: Amy J
authors.initials: AJ
authors.lastname: Davidoff
authors.forename: James F
authors.initials: JF
authors.lastname: Gardner
authors.forename: Brian
authors.initials: B
authors.lastname: Seal
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Edelman
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002289:Carcinoma, Non-Small-Cell Lung / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy; D002294:Carcinoma, Squamous Cell / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy; D008297:Male; D006278:Medicare; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy; D009367:Neoplasm Staging; D011878:Radiotherapy; D018426:SEER Program; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology